In the JournalsPerspective

Resection significantly extends survival in brainstem high-grade gliomas

Adham Khalafallah, MD
Adham Khalafallah

Partial or total resection appeared associated with longer OS compared with biopsy alone among a cohort of adults with brainstem high-grade gliomas, according to study results published in Journal of Neuro-Oncology.

“Brainstem high-grade gliomas are among the rarest and deadliest lesions that pose significant treatment challenges,” Adham Khalafallah, MD, postdoctoral research fellow in the department of neurosurgery at Johns Hopkins University School of Medicine, told Healio.

“Because of the vital nature of this region, high-grade brainstem gliomas have traditionally been treated only by chemotherapy and radiation," he added. "However, in recent years, our institution and several other academic medical centers around the world have been able to safely access tumors through brainstem safe entry zones. Yet, the benefits of aggressive resection have been unclear. Our study aimed to clarify the OS benefit among these patients.”

Khalafallah and colleagues pooled data on 103 adults (mean age, 42.4 years; 57.2% men) with brainstem high-grade gliomas included in the SEER database between 1973 and 2015. Most patients had brainstem glioblastoma (57.3%), followed by anaplastic astrocytoma (21.3%), malignant glioma (19.4%), anaplastic oligodendroglioma (1%) and gliosarcoma (1%). All patients underwent surgical intervention, including biopsy (15%), partial resection (66%) or total resection (19%).

Partial or total resection was associated with longer OS compared with biopsy alone among a cohort of adults with brainstem high-grade gliomas.

Investigators examined associations between survival and demographic data, tumor characteristics and treatment factors. They assessed OS through univariable and multivariable Cox regression analysis.

Median OS was 11 months among all patients, 8 months for those who underwent biopsy, 11 months for those who underwent partial resection and 16 months for those who underwent total resection.

Results of a univariable analysis showed significantly shorter survival among patients aged 50 to 60 years (HR = 2.51; 95% CI, 1.32-4.79) and those aged 60 years and older (HR = 3.95; 95% CI, 1.75-8.91) compared with patients aged 18 to 30 years.

Compared with biopsy alone, researchers observed a sustained survival benefit with partial resection (HR = 0.5; P = .031) and total resection (HR = 0.4; P = .013).

Results of a multivariate analysis that included age, radiation therapy and extent of resection as variables also showed significantly shorter survival among patients aged 50 to 60 years (HR = 2.77; 95% CI, 1.44-5.33) and those aged 60 years and older (HR = 5.3; 95% CI, 2.2-12.72) compared with patients aged 18 to 30 years. Moreover, researchers observed an even greater benefit of more aggressive surgery, including partial resection (HR = 0.32; P = .006) and total resection (HR = 0.24; P < .001), but no survival benefit among patients who received postoperative radiation (HR = 1.57).

“Because of the rarity of brainstem tumors, previous studies have usually comprised a heterogeneous, small group of patients from a single institution. Our findings are more generalizable, as this population-based study is one of the largest to date and consists of a homogenous cohort of patients,” Khalafallah told Healio. “In our future research, it might be possible to boost survival even further by identifying molecular biomarkers that could help personalize which treatments might benefit patients most. Another line of research is further investigating the effect of various treatment plans on the quality of life of our [patients with] brainstem glioma.” – by Jennifer Southall

For more information:

Adham Khalafallah, MD, can be reached at Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287; email: akhalaf2@jhmi.edu.

Disclosures: Khalafallah reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Adham Khalafallah, MD
Adham Khalafallah

Partial or total resection appeared associated with longer OS compared with biopsy alone among a cohort of adults with brainstem high-grade gliomas, according to study results published in Journal of Neuro-Oncology.

“Brainstem high-grade gliomas are among the rarest and deadliest lesions that pose significant treatment challenges,” Adham Khalafallah, MD, postdoctoral research fellow in the department of neurosurgery at Johns Hopkins University School of Medicine, told Healio.

“Because of the vital nature of this region, high-grade brainstem gliomas have traditionally been treated only by chemotherapy and radiation," he added. "However, in recent years, our institution and several other academic medical centers around the world have been able to safely access tumors through brainstem safe entry zones. Yet, the benefits of aggressive resection have been unclear. Our study aimed to clarify the OS benefit among these patients.”

Khalafallah and colleagues pooled data on 103 adults (mean age, 42.4 years; 57.2% men) with brainstem high-grade gliomas included in the SEER database between 1973 and 2015. Most patients had brainstem glioblastoma (57.3%), followed by anaplastic astrocytoma (21.3%), malignant glioma (19.4%), anaplastic oligodendroglioma (1%) and gliosarcoma (1%). All patients underwent surgical intervention, including biopsy (15%), partial resection (66%) or total resection (19%).

Partial or total resection was associated with longer OS compared with biopsy alone among a cohort of adults with brainstem high-grade gliomas.

Investigators examined associations between survival and demographic data, tumor characteristics and treatment factors. They assessed OS through univariable and multivariable Cox regression analysis.

Median OS was 11 months among all patients, 8 months for those who underwent biopsy, 11 months for those who underwent partial resection and 16 months for those who underwent total resection.

Results of a univariable analysis showed significantly shorter survival among patients aged 50 to 60 years (HR = 2.51; 95% CI, 1.32-4.79) and those aged 60 years and older (HR = 3.95; 95% CI, 1.75-8.91) compared with patients aged 18 to 30 years.

Compared with biopsy alone, researchers observed a sustained survival benefit with partial resection (HR = 0.5; P = .031) and total resection (HR = 0.4; P = .013).

Results of a multivariate analysis that included age, radiation therapy and extent of resection as variables also showed significantly shorter survival among patients aged 50 to 60 years (HR = 2.77; 95% CI, 1.44-5.33) and those aged 60 years and older (HR = 5.3; 95% CI, 2.2-12.72) compared with patients aged 18 to 30 years. Moreover, researchers observed an even greater benefit of more aggressive surgery, including partial resection (HR = 0.32; P = .006) and total resection (HR = 0.24; P < .001), but no survival benefit among patients who received postoperative radiation (HR = 1.57).

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“Because of the rarity of brainstem tumors, previous studies have usually comprised a heterogeneous, small group of patients from a single institution. Our findings are more generalizable, as this population-based study is one of the largest to date and consists of a homogenous cohort of patients,” Khalafallah told Healio. “In our future research, it might be possible to boost survival even further by identifying molecular biomarkers that could help personalize which treatments might benefit patients most. Another line of research is further investigating the effect of various treatment plans on the quality of life of our [patients with] brainstem glioma.” – by Jennifer Southall

For more information:

Adham Khalafallah, MD, can be reached at Johns Hopkins University School of Medicine, 1800 Orleans St., Baltimore, MD 21287; email: akhalaf2@jhmi.edu.

Disclosures: Khalafallah reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Ashley L. Sumrall

    Ashley L. Sumrall

    Brainstem gliomas are considered off limits to many neurosurgeons, as they fear inducing neurologic deficits. Many gliomas in this region are considered unresectable by location alone. Given that glioma resectability correlates with improved survival, this is unfortunate for patients. In this study, the researchers included more than 100 patients with brainstem tumors who were able to undergo surgical intervention. Median survival of the cohort was 11 months, and estimates for those who had undergone surgery were higher than what is currently quoted for patients with brainstem tumors who may only have biopsies.

    The authors touch on two primary issues of concern when reviewing brainstem gliomas: the degree of infiltrative tumor and surgical strategies. It would have been helpful to know more about these patients, including further details about postoperative deficits.

    In simpler terms, I would remind physicians that just because you can do something does not mean that you should. In approaching care for these patients, it is best to include a neurosurgeon who specializes in brain tumors and is both technically sophisticated and incredibly thoughtful about patient selection. Survival may be improved by offering gross total resection, but quality of life matters, as well. Patients who may pursue these operations should have extensive, multidisciplinary preoperative counseling by teams that have considerable experience in brain tumor management.

    • Ashley L. Sumrall, MD
    • HemOnc Today Editorial Board Member
      Levine Cancer Institute at Atrium Health

    Disclosures: Sumrall reports no relevant financial disclosures.